Tuesday, May 31, 2011

One of the worst disasters in American history happened today, and is mostly forgotten.

It was the Johnstown Flood. And unless you grew up in Pennsylvania, you may have never heard of it.

Johnstown, Pennsylvania had a population of 30,000 in 1889, and was growing rapidly due to the steel industry. Because of geography the area was prone to flooding, and so the South Fork Dam had been built to protect the city.

When the dam was built (1838 to 1853) it was considered quite solid, but by 1889 had fallen into disrepair. A group of businessmen had lowered the top of the dam to build a road over it, and occasional small leaks were patched with simple materials (like mud). The iron spillways (used to release water in order to prevent collapse) had actually been sold for scrap. Concerns had been raised about its safety several times, but, as always seems to be the case, nothing was done to correct them until it was too late.

On May 30, 1889 a HUGE rainstorm struck, dumping 10 inches (22 cm) of rain over several hours. Elias Unger, the president of a local hunting and fishing club, awoke the next morning to see the lake was almost to the top of the dam.

He quickly assembled a group of men, and, in the pouring rain, with the dam threatening to collapse and kill them, they frantically struggled to prevent disaster. Some worked at the top, piling muddy earth higher to raise its height. Others tried a create a new spillway to relieve pressure. On 2 occasions John Parke rode his horse to the nearest telegraph station, sending messages to Johnstown to warn them of the impending disaster. Both messages were ignored, as there had previously been similar false alarms during storms.

By 1:30 in the afternoon, Unger and his men realized that their efforts were futile, and disaster was inevitable. They gave up and retreated to high ground, and hoped that downriver in Johnstown their messages had been heeded.

At 3:10 p.m. the dam collapsed explosively.

20 millions tons of water from Lake Conemaugh were sent raging downhill toward Johnstown. As it poured down it picked up anything in its path, turning into a gigantic blob of debris. Trees. Homes. Barns. Farm animals. Boulders. It destroyed several smaller towns on the way to Johnstown, and a witness described it as "a huge hill rolling over and over". One small town of 40-50 homes utterly vanished, with nothing but bare rock left behind.

Locomotive engineer John Hess saved many lives in the community of East Conemaugh. He tied his train whistle down, and drove backwards toward the town, hoping they'd hear its screeching. Hess miraculously survived when he was thrown from his train as it was overtaken by the flood.

The flood struck the Conemaugh Viaduct- and stopped as debris blocked its way through the arches under it. But after a few minutes this structure collapsed, and the downhill torrent resumed. This brief stop, then resumption, actually increased the force of the water as it headed downhill.

Just outside Johnstown the flood became even more deadly. It hit the Cambria Iron Works, picking up buildings, railroad cars, factory machines, furnaces, piles of coal, metal plates, and LOTS of barbed wire- and added them to its swirling mass.

At 4:07 p.m. a wall of water and debris, 60 feet (18 m) high, traveling at roughly 40 miles per hour, struck Johnstown. Some frantically ran for attics, only to find the water was too high. Many were crushed or trapped by trees, barbed wire, and other debris that were part of the flood. A large portion of the town was utterly destroyed.

The Johnstown Stone Bridge (still standing today) partially stopped the flood's progression, as debris blocked the arches under it. Unlike the Conemaugh Viaduct, however, this held- and as a result a second flood wave was directed backwards at Johnstown, striking the ruined city from the opposite direction.

To make matters worse, the huge pile of debris trapped at the stone bridge (covering 30 acres and 70 feet [21 m] high) somehow caught fire. It killed 80 people who were seeking shelter on the bridge, and the flames quickly spread back into Johnstown, going to the structures that were still dry and standing. It burned for 3 days, killing many who had escaped the waters.

Two of the most courageous figures in the disaster were Hettie Ogle and her daughter, Minnie. Hettie was a Civil War widow, and she and Minnie were Johnstown's telegraph operators. As the flood roared down, Hettie frantically sent warnings to communities further downriver, saving countless lives. Rather than trying to save themselves the two stayed at their post, tapping out updates and repeated alarms until she sent "this is my last message" as the waters surrounded them.

All together 2,209 people died in a few hours. 396 were children.

800 of the bodies found weren't identifiable, and are today buried in a large "plot of the unknowns" in Westmont, Pennsylvania. An eternal flame is kept alight there in their memory.

The American Red Cross was only 8 years old, and had never handled a large disaster before. Clara Barton, its founder, personally led the efforts. She and her staff arrived in Johnstown as soon as they safely could (5 days later) and stayed there for 5 months. Their tireless work in such circumstances brought the Red Cross great recognition, helping to build it into the organization it is today.

None of the businessmen who'd owned (and neglected) the dam could be held responsible under the prevailing legal actions. American law was subsequently changed to make such people responsible for their actions, and the laws remain in effect today. It forever changed the American system of legal liability.

The stone bridge that partially stopped the flood still stands 122 years later, a grim reminder of the tragedy.

Sunday, May 29, 2011

The doctor's lounge usually has some bagels and muffins every morning, and bread for toast.

Next to the bagels is a bagel slicer, which I'm sure you've all seen. It bears a vague resemblance to a guillotine.

This morning I noticed there was half a bagel in the slicer.

As I sat looking up patient info on a lounge computer, I watched 3 docs come in for bagels. They each took the abandoned half out (which sounded hard as a rock when they set it on the counter), slice their own bagels, THEN PUT THE STALE HALF BACK IN THE SLICER!

It was still there when I went to round. For all I know it will be there when I retire.

Saturday, May 28, 2011

The trick-or treaters had come and gone. I was putting things away, when the doorbell rang again.

I probably shouldn't have answered it, but figured we still had lots of candy, and were better off getting rid of it. So I did.

It was 2 guys. Both wearing pillow cases over their heads. Both with their hands out of sight. They said nothing. One started reaching into his jacket pocket.

Before I could slam the door, Blackdog suddenly lunged out of nowhere, growling and barking. She'd placidly laid in the hall and watched one group of trick-or-treaters after another, without moving. But now she was suddenly out for blood.

The two guys bolted and ran as she came for them. I grabbed her collar and slammed & locked the door.

Thank you, Blackdog, for everything. Your amazing 16 year run of devotion came to a peaceful end last week, and we will miss you.

That's a tough question, and it can be tricky. So here are a few tips to warn you that your doctor may not be real. Any one of these (not to mention ALL of them, FFS) should alert you to look for another doctor.

1. A reputable physician's sole listing will likely NOT be in a Bulgarian language newspaper in Skokie, Illinois.

2. A reputable physician generally will NOT be seeing office patients at 6:30 on a Saturday night.

3. A reputable physician will NOT wait for you, alone, in a dark, locked, building with a "CLOSED" sign in the window.

4. A reputable physcian will NOT let you knock for a while before letting you in himself.

5. A reputable physician will NOT stick toothpicks in your chest.

6. A reputable physician will NOT give you a bottle of pills labeled "Prosperous Farmer" that expired in 2002 (or anything called that, no matter when it expired!)

7. A reputable physician will ALWAYS have some sort of office paperwork.

8. A reputable physician will NOT jump into his car and try to drive away when you return for a follow-up visit.

If your physician does this, and you paid $150 cash for it, then you must have been seeing this guy.

And, for the record, I think it's absolutely pathetic that the patient involved didn't see a problem with items #1-6.

Sunday, May 22, 2011

I've been reminded that USMLE part 1 is fast approaching. So I'm reposting my own memories of the test.

And this clip, from the movie "Real Genius". In 30 seconds it summarizes perfectly what studying for USMLE is like.

Anyway...

At the end of the second year of medical school is the USMLE-1 (United States Medical Licensing Boards, Part 1- the name is misleading, several countries use it). This covers every subject from the first 2 years of medical school: Anatomy, Biochemistry, Pathology, Pharmacology, Microbiology, Neuroanatomy, Physiology, Histology, and a few others. 2 years of learning, all in 1 awful test. When I took it the test consisted of 4 sessions spread out over 2 days. Each session had 200 questions, and 3 hours to answer them.

At my school, if you failed the test, you had to take it again. If you failed it twice, your medical career was over (though you still owed your student loans back).

It was the Summer of 1991.

I don't remember the specific dates. But basically, between the time med school ended for the Summer, and the dreaded test, was roughly 1 month. You had 30 days to re-study everything that had taken you 2 years to learn to that point. And pretty much your chances of a career in medicine depended on how you did.

So it was stressful. And, to this day, I still feel for all of you who are out there studying for it now. Any classmate, resident, or attending who tells you they weren't scared is lying.

Within hours of the semester ending, my class had gone into hiding.

I stopped shaving, to save time. My roommate, Enzyme, disconnected our TV, moved it across the room, and piled furniture in front of it.

My days consisted of me getting up at 7:30. I'd either stay at my apartment desk or walk over to campus to find an empty classroom to study in. I'd put in my trusty earplugs and the world around me ceased to exist.

Around noon I'd go back to my apartment for a PBJ, then go study again. At 5 I'd go back to my place for a sandwich, or ramen soup, or Rice-a-Roni. I'd sit out on my balcony and eat, for 15 minutes of relaxation. Or I'd read a book with dinner (Enzyme and I were both reading a single copy of "The Price of Admiralty" by John Keegan. It sat on our kitchen table for the month, and we'd have different eating times so we could share it). I never spent more than 30 minutes on a break. After dinner I'd go back to my desk, or campus. I'd study until around 3 a.m., then go home to sleep for a few hours.

I called my parents a few times. My daily outfit consisted of gym shorts (the short kind, from the 80's), T-shirt, sneakers, and the growing beard. Days blended together. There were no differences between weekends and weekdays. People I encountered were superfluous to my existence. I saw my classmates a few times, and we exchanged glassy-eyed nods as we passed.

I shaved a night or two before the test. I studied until around 11:30 p.m. on the eve of the test, re-reviewing a few last points.

It was weird, like I was living alone on another planet for 30 days. I have no idea what happened in the news that month. I was out-of-touch with everything but my books.

If there's one thing I came out of medical school with, it was this: The realization that there was absolutely, positively, no way you were EVER going to get everything read, studied, and reviewed that you needed to before the test.

And, somehow, when the test was over and the dust had settled, you'd done it. And you'd have no idea how. I still don't.

Saturday, May 21, 2011

Occasionally someone will write in wondering why I became a neurologist. It was mostly by process of elimination, as I learned other things just weren't for me.

My pediatric career died fast in med school.

That rotation, during my 3rd year, was 8 weeks long. It took me 15 minutes to realize I didn't want to do this for a living. So I was left with 7 weeks, 6 days, 23 hours, and 45 minutes of waiting it out (and pretending to have a deep interest in hearing about the color of a child's diarrhea/mucus/whatever).

1. I can't see a tympanic membrane in a baby's ear canal (and am convinced most pediatricians just confabulate the "it's a little red" line).

2. I remember trying to examine a hysterically screaming infant in pediatric clinic. It was screaming before I went, in, and me trying to listen with a stethoscope only made things worse (and damaged my hearing).

Finally the mother said "FOR GOD'S SAKE! MAKE HIM STOP CRYING!!!"

So I left the room. That seemed to do the trick.

And that was how I realized I had absolutely no interest in doing peds.

Sorry I refused to work you in yesterday afternoon. I had an open slot, and would much rather see you here, and get paid for it, then have an empty hour.

But when you called Mary and said you'd had a horrible headache all morning, and couldn't move your right arm very well, she quickly became alarmed that this wasn't something that should be handled in my office. In fact, she told you to call 911, and you refused, saying you'd rather just drive over to see me.

That personally alarmed me, because obviously you shouldn't be driving in your condition. When Mary told me that I decided to get on the phone myself.

Your speech was a bit slurred, and I again reiterated that you should call 911. I even offered to call them for you, and asked for your address or phone number, so I could get them to your house. You refused, on the grounds that your co-pay for an ER visit was higher than it was to come to my office.

Then you told me that you didn't want to see me anyway, because obviously I didn't care about someone who needed help. And you hung up.

Wednesday, May 18, 2011

This letter came in today from a reader who says he's working at the NIH.

"I shadowed a pediatric neurologist this week. It was certainly interesting, but up until today I'd have guessed your blog was a little exaggerated in terms of humor.

That was before clinic this afternoon.

I saw the patient, an adorable four year old girl, grab the neurologist's reflex hammer from out of her coat, run over to the PA, and, uh, test his reflexes.

I'm not a physician, so I'm not sure if grabbing your crotch after it's been walloped with a reflex hammer is actually a reflex, but it sure was funny. Well, maybe not for the PA.

The kid really, really liked that hammer. The attending actually GAVE IT BACK to her later to buy her cooperation in the exam. I shielded my groin, so the patient had to settle for beating my leg with it.

Seems like a great field. I'll just remember to wear a cup."

Thank you! Just remember, folks- anyone who thinks this stuff doesn't happen, hasn't had the misfortune to work in the medical field.

Saturday, May 14, 2011

I'm sorry about the way things went at your appointment yesterday. I guess you and I just didn't have great chemistry.

I can understand you being frustrated with me. Obviously, a man of your means is used to people kissing his ass constantly. But here at Grumpy Neurology, it doesn't buy you much. Let's face it, Medicare pays me the same amount to put up with you as it pays me to put up with Mr. Nice Butpoor. If you were paying me $1000/hour to listen to your stories about the yacht club I might be more inclined to do so. But I'm only going to get Medicare's flat $115 for you, and my billing company gets 10% of that, and I have to pay Mary, Annie, my rent, the Diet Coke bill, and my malpractice insurance out of the rest.

Anyway, we were obviously off to a bad start when you told Mary that your regular doctor (who you pay cash to) dresses up for you. And this was before you even had a look at me. You also were not happy that, when you asked Mary what kind of refreshments we offer for waiting patients, she pointed to the water cooler.

I SO enjoyed being grilled over my credentials. I really am a doctor, I swear, not some homeless person who decided to rent an office, hire some staff, and buy some cheap office furniture just for the hell of it. You were clearly not impressed that I went through public schooling most of my life. Of course I've heard of your alma mater, but it was so much more fun to watch the horrified expression on your face when I pretended I hadn't, and then asked you if it was in Arkansas. The devil made me do, what else can I say?

I think we reached the low point during the appointment when, after I'd spent 30 minutes taking your windy history, and another 20 minutes examining you, your heavily plasticized wife (who may be putting arsenic in your prunes- watch out) asked me "So when will the doctor come in to talk to us?" That made me feel real special.

So when I heard you tell Mary that you didn't want to schedule a follow-up with me, and wanted to discuss matters with your internist, I knew this translated to "I'm never coming back here and am complaining to my internist about you". And guess what? I don't care.

Be careful the automatic door doesn't hit... oh, sorry, guess I should have warned you sooner.

Thursday, May 12, 2011

Dr. Grumpy: "Pete, it's been years since your last seizure. What happened?"

Mr. Ictal: "I didn't take it on Saturday."

Dr. Grumpy: "Why did you stop?"

Mr. Ictal: "Because you told me to!"

Dr. Grumpy: "What?... I don't have anything like that in your notes."

Mr. Ictal: "At our last visit you reminded me not to drink excessively on Noseizure! So, since my buddies were all in town, and I knew we were going to get wasted on Saturday night, I stopped taking it for the day."

Monday, May 9, 2011

In doing further research I learned that the wild beaver attacked a man who was out fishing. I can only assume he was quite surprised to be assaulted in such fashion. He is reportedly doing fine at this time.

Saturday, May 7, 2011

My first rotation as a 3rd year medical student (determined randomly at my school) was psychiatry.

Your first day on clinical rotations you never know what to expect. I was assigned to evaluate Mr. Binford, who'd been picked up by police (for vandalism) the night before.

I sat down and nervously spoke to Mr. Binford. He was a bit disheveled, but seemed intelligent and reasonable. He owned a home improvement company. He employed several handymen (including himself) and had a central dispatch office. They did all ranges of home and yard work.

It all sounded pretty reasonable to me. So, being young and naive, I presented the case to my attending psychiatrist. When he asked me what I thought, I told him that this person didn't seem to need psychiatric care.

Then he asked me if I'd read through his past chart. Sheepishly I admitted I hadn't, because I'd been in a hurry to interview the patient early on my first day.

So he handed me the chart.

OMG

The patient owned no such business. He had a remarkably intricate delusional system.

He owned a truck full of power tools, paint, and various other home repair supplies. Of which he had some knowledge about using them.

He drove around the city, day and night, and would randomly stop at houses where he thought they'd called him for work.

People would come home (or be woken up at night) to find him doing unneeded work on their houses. Cutting down trees. Painting their outside walls. Knocking holes for windows in their homes. Taking apart pool filters. In one case he'd actually painted a guy's car with house paint.

I learned that old charts were useful.

I also learned that even the incredibly delusional could make a lot of sense when you didn't know their background.

We called him "Psycho Home Repairman".

And to this day, if one of our neighbors turns on a lawnmower or other loud equipment after dark, I go to the window... Just to make sure.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

Singing Foo!

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Note: I do not answer medical questions. If you are having a medical issue, see your own doctor. For all you know I'm really a Mongolian yak herder and have no medical training at all except in issues regarding the care and feeding of Mongolian yaks.